Philippines- AG USRN- Associate III BPM

Overview USRN - A&G Taguig, National Capital Region, Philippines BE THE FIRST TO APPLY JOB DESCRIPTION In this role you should independently be able to effectively and efficiently process the transactions assigned in a timely manner, clarify complex transactions to others and ensure that quality of output and accuracy of information is maintained, in alignment with SLAs. - Investigate and process complex grievances and appeals requests from members and providers - Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity - Review, research, and prepare documentation related to appeals and grievances in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards - Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review - Document and logs appeal/grievance information on relevant tracking systems - Generate written correspondence to providers, members, and regulatory entities - Serve as a subject matter expert for appeals, grievances, and quality of care issues - Utilize leadership skills - Assist with or perform other relevant essential functions as required Qualifications: - Unrestricted USRN mainland license - At least 2 years experience in utilization management / review - Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes. Medicare Advantage experience an advantage - Excellent written and verbal communication skills. - Excellent customer service and interpersonal skills. - Working knowledge of current industry Microsoft Office Suite PC applications. - Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management - Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings, and levels of service - Knowledge of applicable accreditation standards, and local, state, and federal regulations - Appeals and grievance experience required. - Strong problem-solving skills, facilitation skills, and analytical skills. - Flexible to work in globally distributed teams and on business need support weekend transactions Originally posted on Himalayas